COVID ICU Experience Leads UMass Surgical Resident Chan to Study CPR Survival

Daniel J. Baldor, MD, MPH

A new controlled study from UMass Chan Medical School provides evidence for the first time that could inform doctors about which very ill or injured patients would be most likely to benefit from cardiopulmonary resuscitation (CPR).

The study led by Daniel J. Baldor, MD, MPH, Chief Resident in General Surgery, and colleagues found that “full code” status, including aggressive CPR, provided no survival benefit over DNR status among the most critically ill, those with an expected mortality rate greater than 75%, as determined by the Apache IV score, an assessment of disease severity. In less severely ill patients, full code status was associated with improved survival. The article was published in journal of critical care medicine.

Dr. Baldor was deeply affected by his CPR experiences on COVID intensive care unit patients who the medical team knew would not survive. He spent hours with families of patients trying to help them come to terms with the inevitable death.

“Part of that,” he explained, “is due to media misconceptions, where there’s a 60 to 100 percent survival rate for in-hospital CPR on TV shows. In real life it’s usually around 20-30%, half of those with some form of remaining disability.

Such scenarios in which healthcare providers perform “futile CPR”, i.e. resuscitations that have an extremely low probability of survival, do not achieve the patient’s broader goals, and are performed against the best judgment of the health care team due to patient or family demands are not uncommon, according to Baldor. Futile CPR can be physically traumatic for the patient and adversely affect the mental health of clinicians.

“CPR is a procedure that has been placed in a unique category,” Baldor said. “Acts are also not indicated when they have no effect, especially if they are harmful or costly. CPR saves the lives of some patients, but for many it is considered futile.

Baldor wanted to know why the practice of futile CPR was often the norm, but found no controlled studies on which to guide patient selection for CPR candidacy. So he took on a research project that he hoped might directly affect a problem he saw.

“Nobody wants to do futile CPR, but the problem with saying something isn’t indicated is that you need really good evidence to say that,” Baldor said. “There has never been a controlled study of CPR before this. This represents a higher level of evidence to help guide the decision-making process.

The research team hypothesized that the protective effects of CPR diminish as disease severity increases. They looked at 17,710 intensive care encounters from five hospitals, stratifying by predicted mortality quartiles using Apache IV scores and analyzing survival between full-code and DNR patients in each quartile. Patients were followed for a median of 760 days.

In addition to finding that CPR intervention was associated with prolonged lifespan in patients in the first three quartiles of disease severity, but not the sickest or most traumatized, the researchers identified a progressive decrease in Survival benefit for full code patients compared to DNR patients as disease severity increases. The researchers suggested that this model shows a possible ceiling effect of full-code CPR to improve survival.

Baldor said the study needs to be repeated with a larger data set and in multiple health systems. Most importantly, advance directives and conversations about end-of-life care need to become more mainstream.

“Culturally, in the United States where we don’t do death, the dying process is hidden in hospitals,” Baldor said. “And so we don’t deal with it until we’re confronted with it.”

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UMass infectious disease expert Chan shares insights on virus, vaccines and treatment

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